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 Ombudsman Report

Investigation into the

Hamilton Niagara Haldimand Brant
Local Health Integration Network’s
use of community engagement
in its decision-making process

“The LHIN Spin”

André Marin
Ombudsman of Ontario
August 2010
Table of Contents

Overview ........................................................................................................................................ 1
Investigative Process..................................................................................................................... 3
Evolution by Devolution: The LHINs Emerge........................................................................... 4
Defining Community Engagement........................................................................................................ 7
The HNHB LHIN is Born .................................................................................................................... 11
The Community Gets Engaged............................................................................................................ 11
Hamilton Health Sciences "Access to Best Care" Plan..................................................................... 14
Niagara Health System "Hospital Improvement Plan".................................................................... 17
Rules of Engagement .................................................................................................................. 21
Opinion ........................................................................................................................................ 23
Recommendations ....................................................................................................................... 24
Responses ..................................................................................................................................... 25
Ministry Response ................................................................................................................................ 25
LHIN Response ..................................................................................................................................... 28
Appendix: Final response letters……………………………………………………………....37

!
Overview
1 Government officials touted the arrival of the Local Health Integration Networks as
heralding a new era in community health care. Citizens, health service providers and other
stakeholders were repeatedly told by government representatives that under the LHIN
system, they would have a voice in the health services decisions that affected them. The
public was assured that with the advent of the LHINs, an aloof, centralized bureaucracy
would no longer be making significant decisions about the future of community health
services. Instead, decisions would be informed by local needs and priorities, and made in
and by the community for the community.

2 Unfortunately, while it is true that as a result of the LHIN model, the Ministry of Health
and Long-Term Care has been able to distance itself from difficult decisions surrounding
the integration and funding of regional health services, the reality of community decision-
making has fallen far short of the political spin.

3 While members of the 14 LHIN boards of directors are selected from their communities,
the extent to which the broader public is actually engaged in decision-making remains
undefined and inconsistent. The Local Health System Integration Act, 2006 provides
limited direction when it comes to community engagement. There are no clear minimum
standards for soliciting community views on systemic priorities or specific integration
plans, and different LHINs interpret their public outreach obligations differently.
Understandably, this has led to considerable confusion about the nature of community
engagement carried out by both health service providers and the LHINs. This has
engendered growing public frustration with LHIN decisions in some areas.

4 My Office received more than 60 complaints about two controversial local health services
restructuring plans affecting residents in the Hamilton Niagara Haldimand Brant region:
The Hamilton Health Sciences “Access to Best Care Plan” and the Niagara Health System
“Hospital Improvement Plan.”

5 The Hamilton Niagara Haldimand Brant Local Health Integration Network (HNHB LHIN)
has taken steps to obtain local stakeholder views on the general state of the health care
system in its region, which it has used to inform its long-term strategic vision for health
services. However, when it comes to concrete planning relating to individual restructuring
plans, which promise to have direct and immediate impact on the lives of local residents,
many citizens have been highly critical of the adequacy of community engagement. One
of the core problems we identified was that the LHIN had not educated the public about
what to expect in the way of community engagement through health service providers and
its own processes.

6 The HNHB LHIN, like its counterparts throughout the province, is charged with making
tough decisions. Inevitably, the LHIN will never please all stakeholders – that is why it is
critical that LHINs operate as transparently as possible. Under the Local Health Services

1
“The LHIN Spin”
August 2010
! !

!
 Integration Act, LHINs in Ontario are required to hold meetings that are open to the public,
subject to a limited number of prescribed exceptions. However, similar to other LHINs,
the Hamilton Niagara Haldimand Brant LHIN has adopted a template by-law which
purports to permit its board of directors to meet behind closed doors for “education
sessions.” The LHIN followed this practice when considering the two restructuring plans,
which led to complaints to my Office.

7 Unfortunately, this practice is antithetical to the LHIN model. It serves to undermine the
integrity and credibility of the LHIN’s decision-making, and in my view, is simply illegal.
Any possible advantage gained by the board in meeting in private is inevitably lost by the
risk of inciting public suspicion around unpopular decisions.

8 The LHIN model may represent an evolution in local health services planning, but it is not
without its growing pains. Community engagement is fundamental to the success of the
LHIN model, and my investigation has revealed that, at least in the case of the HNHB
LHIN, community engagement has not lived up to its promise. Accordingly, in this report
I am making three recommendations addressed at improving the situation. First, in order
to inject greater accountability and consistency into the LHIN decision-making process
generally, I am recommending that the Ministry of Health and Long-Term Care consider
putting forward guidelines setting out minimum standards relating to community
engagement to be undertaken by both health service providers and LHINs. Second, I am
recommending that the HNHB LHIN educate the public using its website, meetings and
other methods concerning its general practices relating to community engagement as well
as the nature of community engagement to be expected with respect to specific plans under
consideration. And finally, I am recommending that the LHIN amend its By-law 2 and
immediately cease its practice of holding closed educational sessions or other private
meetings in contravention of the Act. In addition, I have recommended that both the
Ministry and the HNHB LHIN report back to me on their progress in implementing my
recommendations.

9 The Ministry has signalled a willingness to take steps to enhance the openness and
transparency of the LHIN decision-making process, and has undertaken initiatives recently
to address community education guidelines. However, despite its lip service to the
principle of transparency, the Ministry is not fully committed to openness with respect to
the LHIN process. In initially responding to my recommendations, the Ministry did not
take issue with my conclusion that the open meeting requirements of the Local Health
System Integration Act, 2006 prevent LHINs from holding closed and unannounced
meetings during which information is obtained and discussed relevant to their decision-
making. However, the Ministry recently flip-flopped, taking the position that all LHINs
are free to hold “education” meetings that are closed to the public provided no actual
decisions are reached during these secret sessions. The Ministry’s attempt to justify this
clandestine practice is very disturbing and clearly inconsistent with the plain wording of
the legislation. Unfortunately, the Ministry’s stance allows for the perpetuation of the air
of mystery that we found surrounded the HNHB LHIN’s decision-making. In my view, it

2
“The LHIN Spin”
August 2010
! !

!
 is antithetical to the community engagement principles in the Act, wrong in law, and does
not serve the public of Ontario well. I note that the Deputy Minister wrote in his July 15,
2010 letter to my Office that “the Ministry is continuing to review the situation with
respect to your concerns related to educational meetings” and that the Ministry “will be
taking action to clarify educational meetings and enhance the already extensive regulatory
framework designed to foster openness and transparency.” I sincerely hope that the
Ministry will ultimately reconsider its position regarding the application of the open
meeting requirement.

10 As for the HNHB LHIN, it did not accept my findings and opinions concerning its role
with respect to community engagement and the legal requirement to hold public meetings.
The HNHB LHIN also did not commit to take any action in response to my
recommendations. While recently the LHIN has taken some steps towards greater
transparency concerning community engagement, its attitude, combined with its failure to
follow an open and transparent process, threatens to erode public confidence in decision-
making relating to the local health system.

Investigative Process
11 On September 5, 2008, our Office received a complaint from a resident of the Niagara
region about the lack of public consultation undertaken by the HNHB LHIN regarding the
proposed restructuring of the Niagara Health System. Soon after, we received a complaint
from Hamilton Centre NDP MPP Andrea Horwath that the same LHIN had failed to
comply with its community engagement obligation in connection with its decision on a
voluntary integration plan proposed by Hamilton Health Sciences. As we were reviewing
these complaints, we received 38 more about the LHIN’s community engagement when
deciding on restructuring plans.

12 The complaints focused on the Hamilton Health Sciences “Access to Best Care Plan,” and
the Niagara Health System “Hospital Improvement Plan.”

13 While I received complaints about the content of the plans and the adequacy of the
community engagement undertaken by the involved health service providers, I have no
authority to consider these matters, as hospitals do not come within my jurisdiction. The
LHIN, however, is a provincial governmental organization coming within my mandate,
and the issue of the sufficiency of the community engagement it undertook when arriving
at its decisions is something that I can address.

14 On March 24, 2009, I advised the Ministry of Health and Long-Term Care and the HNHB
LHIN of my intention to investigate. After the investigation was publicly announced, we
received another 26 complaints from municipal leaders, health care professionals,

3
“The LHIN Spin”
August 2010
! !

!
 community associations and individual residents, all of whom highlighted community
engagement as a key concern.

15 A Special Ombudsman Response Team (SORT) of four investigators and an Early

Resolution Officer was assigned to conduct the investigation. The team conducted 51
interviews, including with all eight members of the LHIN board, as well as a number of
LHIN staff.

16 In-depth interviews were also conducted with 33 complainants, municipal leaders, health
care professionals, community associations and residents, as well as senior representatives
from other LHINs, and government health officials in other jurisdictions. Investigators
also interviewed officials from the Ontario Ministry of Health and Long-Term Care LHIN
Liaison Branch, the Ontario Medical Association and the Ontario Hospital Association.
Most interviews were tape-recorded and transcribed.

17 The team also reviewed extensive documentation, including 35 binders of documents

received from the HNHB LHIN, as well as documents received from the Ministry of
Health and Long-Term Care. The SORT team received excellent co-operation from both
the LHIN and the Ministry.

Evolution by Devolution: The LHINs Emerge

18 Historically, health services in Ontario were funded through the Ministry of Health and
Long-Term Care, which dealt directly with hundreds of health service providers in
communities throughout the province. In September 2004, the then Minister of Health and
Long-Term Care, George Smitherman, announced that the government would be launching
a new local and integrated approach to the funding of health services in Ontario, through
the creation of 14 Local Health Integration Networks, or LHINs.

19 While the Ministry would retain an overarching strategic stewardship role, the LHINs
would be delegated authority to make decisions affecting the funding and delivery of local
health services. Once the LHINs were operational, responsibility for approximately $20
billion, which in 2004 represented two-thirds of Ontario’s health care budget, would
devolve to the local level.1

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
"!Health care spending has since increased to the point where it now represents about 46 cents out of every dollar of
Ontario government program spending. The Ministry of Health and Long-Term Care’s budget is estimated at more
than $44.4 billion for the 2010-2011 fiscal year, with more than $21.5 billion going to the LHINs and related health
service providers, representing just under 50% of the Ministry’s overall spending.

(Ontario Ministry of Finance, 2010 Ontario Budget, Sector Highlights, Health

<http://www.fin.gov.on.ca/en/budget/ontariobudgets/2010/sectors/health.html> (last accessed 24 June 2010); and

4
“The LHIN Spin”
August 2010
! !

!
 20 The LHINs were touted as “the next evolution of health care in Ontario … a made-in-
Ontario solution.”2 The basic premise underlying the LHIN model is that a community’s
health care should reflect community needs, and be planned, co-ordinated and funded in an
integrated manner within and by local communities.

21 While the legislation that would bring the LHIN system into being was still in the drafting
stages, the Ministry began to work on establishing the LHIN infrastructure. During
November and December 2004, the Ministry’s System Integration Team conducted a
series of workshops in the 14 communities in Ontario that would eventually form the
geographic boundaries for the LHINs. The team met with about 4,000 people, including
citizens, health service providers, and community and patient advocacy organizations. As
a result of these workshops, the Ministry identified existing and future integration priorities
for the various communities. The team submitted 14 integration priority reports to the
Ministry in February 2005.

22 In June 2005, the Ministry began setting up 14 non-profit corporations, which would
become the future LHINs.

23 While development of the LHINs proceeded, Bill 36, the Local Health System Integration
Act, 2005, was introduced in the Legislature in November 2005. By March 28, 2006, the
Act had received royal assent. Under the Act, the LHINs are responsible for planning,
integrating and funding the health care system in each of 14 geographic areas designated
by the Ministry. The 14 corporations established before the Act came into force became
the LHINs upon its enactment. The Ministry provided the chair of each LHIN with the
integration priority reports to inform their integrated health services plans.

24 The LHINs were gradually provided with their statutory authority, receiving full funding
responsibility on April 1, 2007. Since that date, instead of the Ministry paying hospitals,
community care access centres and other health service providers directly, the Ministry has
provided funding to the LHINs for distribution. The Ministry and each LHIN must enter
into an accountability agreement that includes specific goals and objectives. In turn, each
LHIN enters into a service accountability agreement with each health service provider that
it funds, which sets out the obligations and expected outcomes for health delivery services.
Every three years, each LHIN must develop an integrated health services plan, setting out
priorities for its community.

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Ontario Ministry of Finance, Expenditure Estimates, 2010-2011, Vol. 1 (April 22, 2010) Health and Long-Term
Care <http://www.fin.gov.on.ca/en/budget/estimates/2010-11/volume1/MOHLTC.html> (last accessed 24 June
2010).
2
Ontario, Health Results Team, Ministry of Health and Long-Term Care, Health Results Team First Annual Report
2004-05 (Toronto: Queen’s Printer, 2005) at 4.

5
“The LHIN Spin”
August 2010
! !

!
 25 One of the purposes behind the LHIN approach was to eliminate unnecessary duplication
in the provision of health services and better co-ordinate services within the community.
To that end, each LHIN and health service provider is required – separately and in
conjunction – to identify opportunities to integrate the services of the local health system
to provide appropriate, co-ordinated, effective and efficient services. 3

26 The LHINs are Crown agents, governed by boards of directors appointed by the provincial
Cabinet and approved by the Lieutenant Governor. The government has indicated that
LHIN directors are selected from the communities that the LHINs are intended to serve.
To qualify for part-time positions on a LHIN board, appointees must have a background in
health care, public administration, management, accounting, finance, law, human
resources, labour relations, communications, or information management. Each LHIN also
has a salaried chief executive officer and may hire additional staff.

27 While the Local Health System Integration Act was being considered in the Legislature,
rather lofty statements were made about the LHIN model and its emphasis on engaging the
community in local decision-making. For instance, the then Minister of Health and Long-
Term Care, Mr. Smitherman, reinforced community involvement in LHIN decision-
making on several occasions. In November 2005, he said:

Local health integration networks will also have a duty, I daresay an obligation, to
consult with communities about the decisions that are before them. This
legislation makes it very clear that decisions must be made on the basis of public
interest and in the full view of the public.4

28 In April 2006, he said:

Community involvement stands very strong. We believe fundamentally that the

health care system which belongs to the people of Ontario needs to come under
more of their influence. We need to open up their opportunities to influence it
and offer their views on how it can be enhanced.5

29 Consistent with the LHIN model’s emphasis on local decision-making, the Act expressly
refers to “community engagement.”

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
3
Local Health System Integration Act, 2006, S.O. 2006, c. 4, s. 24 [Local Health System Integration Act].
#!Ontario,
Legislative Assembly, Official Report of Debates (Hansard), (24 November 2005) at 1400 (Hon. George
Smitherman).
5
Ontario, Legislative Assembly, Official Report of Debates (Hansard), (6 April 2006) at 1510 (Hon. George
Smitherman).

6
“The LHIN Spin”
August 2010
! !

!
Defining Community Engagement
30 The Act provides that one of the objects of the LHINs is to engage the community of
persons and entities involved with the local health system in planning and setting priorities
for that system, including establishing formal channels for community input and
consultation. 6

31 In addition, each LHIN is expressly required “to engage the community of diverse persons
and entities involved with the local health system about that system on an ongoing basis,
including about the integrated health service plan and while setting priorities.”7

32 “Community engagement” is not defined in the Act, but it does specify that “community”
includes patients and other individuals in the geographic area of the network, health service
providers and any other person or entity that provides services in or for the local health
system and employees involved in the local health system. 8 The Act also indicates that the
methods for carrying out community engagement may include holding community
meetings or focus group meetings or establishing advisory committees.9 Community
engagement must also include prescribed aboriginal, First Nations and French-language
health planning entities.10 In addition, the LHINs are required to establish a health
professionals advisory committee. 11

33 While each LHIN is responsible for community engagement in system planning, each
health service provider is required “to engage the community of diverse persons and
entities in the area where it provides services when developing plans and setting priorities
for the delivery of health services.”12 This obligation is reinforced in the service
accountability agreements entered into between LHINs and health service providers.

34 The Act provides that the province may make regulations respecting community
engagement including how and with whom a LHIN or a health service provider shall
engage the community, the matters about which a LHIN or a health service provider must

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
6
Local Health System Integration Act, supra note 3, s. 5(c).
7
Ibid., s. 16(1).
8
Ibid., s. 16(2).!
!!Ibid., s. 16(3).
10
Ibid., s. 16(4).
11
Ibid., s. 16(5).
12
Ibid., s. 16(6).

7
“The LHIN Spin”
August 2010
! !

!
 engage the community, and the frequency of the engagement.13 However, no regulations
further refining the community engagement obligation have been issued.

35 In addition, the Act provides that when a LHIN requires a health service provider to
proceed with an integration of health services or orders a health service provider not to
proceed with a voluntary integration of services, the public is entitled to notice of the
proposed decision and 30 days to make written submissions in response.14 The Act also
underscores the transparency of the LHINs’ decision-making process by requiring that all
the meetings of the LHIN boards are to be open to the public, subject to a limited number
of specific exceptions.15 The public may only be excluded if:

(a) financial, personal or other matters may be disclosed of such a nature that the
desirability of avoiding public disclosure of them in the interest of any person
affected or in the public interest outweighs the desirability of adhering to the
principle that meetings be open to the public;
(b) matters of public security will be discussed;
(c) the security of the members or property of the network will be discussed;
(d) personal health information, as defined in section 4 of the Personal Health
Information Protection Act, 2004, will be discussed;
(e) a person involved in a civil or criminal proceeding may be prejudiced;
(f) the safety of a person may be jeopardized;
(g) personnel matters involving an identifiable individual, including an employee of
the network, will be discussed;
(h) negotiations or anticipated negotiations between the network and a person,
bargaining agent or party to a proceeding or an anticipated proceeding relating to
labour relations or a person’s employment by the network will be discussed;
(i) litigation or contemplated litigation affecting the network will be discussed, or any
legal advice provided to the network will be discussed, or any other matter
subject to solicitor-client privilege will be discussed;
(j) matters prescribed for the purposes of this clause will be discussed; or

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
13
Ibid., s. 37(1)(f).
14
Ibid., ss. 26 and 27.
15
Ibid., s. 9.

8
“The LHIN Spin”
August 2010
! !

!
 (k) the network will deliberate whether to exclude the public from a meeting, and the
deliberation will consider whether one or more of clauses (a) through (j) are
applicable to the meeting or part of the meeting.

36 The LHIN board must deliberate and vote publicly about whether to exclude the public
from a meeting, based on the permitted exceptions. A motion to exclude the public must
also clearly state the nature of the matter to be considered at the closed meeting and the
general reasons why the public is being excluded.

37 The degree of community engagement that a LHIN is required to undertake was the subject
of a 2008 court challenge. In Ontario Public Service Employees Union v. Central East
Local Health Integration Network,16 the Ontario Superior Court of Justice considered
whether the Central East LHIN should have engaged in public consultation with respect to
the Rouge Valley Health System’s deficit elimination plan, which called for the
consolidation of mental health services within the two sites it operated. After reviewing
the plan, the Central East LHIN had agreed to enter into a revised service accountability
agreement with the service provider. It had also required that the service provider conduct
public consultation prior to implementing its plan. The court rejected arguments that the
LHIN should have consulted with the public in these circumstances. The court found that
the situation did not trigger the requirement to provide formal notice to the public and an
opportunity to make written submissions. In addition, the court noted that the general
obligation of the LHIN to engage the community about the “system” had been satisfied
when the Central East LHIN developed its integrated health service plan. The court
observed that:

… general statements about the importance of community engagement,

particularly in the setting of priorities and development of an HSP [health
services plan], are not sufficient to give rise to an enforceable right to
consultation about LHIN funding decisions.

38 A concern had also been raised in that case that the LHIN had improperly held in camera
meetings. The Court did not address this issue, since no decisions had been made at the
closed sessions and no claim for relief turned on it.

39 At present, “community engagement” is a rather nebulous concept, which individual

LHINs are left to interpret and apply, based on assessments of their local community
needs. It has been noted that despite the requirement for LHINs to engage the community,
there is “very little specificity in the legislation about how [community engagement]
should be carried out, with whom and through what methods.” And as a result, “LHINs
have largely been left on their own to develop their own [community engagement]

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
"$!2008 CanLII 41820 (Ont. Div. Ct).

9
“The LHIN Spin”
August 2010
! !

!
 plans.”17 An official at the Ministry’s LHIN Liaison Branch suggested to us that this
legislative imprecision was deliberate and intended to allow the various LHINs flexibility
in meeting their mandate. During our investigation, many of the representatives from
LHINs throughout Ontario expressed the view that this aspect of the community
engagement provisions was a positive factor that permitted engagement to be adapted to
suit local needs. On the other hand, some community members were quite critical of the
uncertainty that this approach engendered and suggested that there should be clearer
legislative parameters.

40 It is possible that over time more consistency might develop with respect to the nature of
community engagement conducted in Ontario. In March 2009, the 14 LHINs collaborated
with an independent health policy organization to mount a symposium and workshop
“Community Engagement & the LHINs: Truths and Consequences.”18 The participants
shared their experiences, perspectives and understanding about the importance,
opportunities and challenges of community engagement faced by the LHINs. In June
2009, the web resource “Engaging People, Improving Care (EPIC),” was made available to
the LHINs and public as a result of the collaboration of the Ontario Hospital Association,
health service provider associations and LHINs. It includes best practices relating to
community engagement.19

41 At present, there is no mandatory minimum standard that must be met to satisfy a LHIN’s
public outreach obligation. This gap continues to leave open the possibility that citizens in
different regions of the province will experience a considerable variance in the quality and
quantity of community engagement.

42 Certainly, many of the people who complained to our Office about the Hamilton Niagara
Haldimand Brant Local Health Integration Network suggested that they would have
benefited from greater guidance or information concerning what to expect from
community engagement.

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
17
Community Engagement & the LHINs: Truths and Consequences, Symposium and Workshop Summary Report March 11,
2009; pg. 16
18
This symposium and workshop was held on March 11, 2009. It was a collaboration between Ontario’s 14 LHINs and The
Change Foundation.!!

"%!The HNHB LHIN’s website includes this link to EPIC: http://www.epicontario.ca/Home.aspx .!

10
“The LHIN Spin”
August 2010
! !

!
The HNHB LHIN is Born
43 The Hamilton Niagara Haldimand Brant LHIN was first introduced to its community in
June 2005. It covers an area of approximately 7,000 square kilometres and includes the
City of Burlington and much of Norfolk County. There are approximately 250 health
service providers within its boundaries and 1.4 million Ontarians, making it the second-
largest LHIN in the province, per capita. Currently, the LHIN has an annual budget of
approximately $2.2 billion, of which $5 million is used to operate the LHIN20 and the rest
earmarked for transfer to health service providers.

44 The LHIN has eight part-time directors, as well as a Chief Executive Officer and 31 staff
positions. It is based in Grimsby.

45 The LHIN board is responsible for decision-making with regard to health services
planning, integration and funding within its region. The board meets once per month in
open session. It also holds closed “education” sessions, during which it obtains additional
information on specific plans and issues that are before it or that it would like to learn more
about. By-Law No. 2 states that a board meeting “for social, educational or purposes other
than conducting Corporation business is not a Board Meeting.” The LHIN’s By-law 2 is
based on a template that has apparently been adopted by LHINs throughout the province.
During its private “education” sessions, the LHIN board meets with groups or persons it
believes will help it reach a better understanding of the issues before it. However, all
decisions are made in open session.

46 The HNHB LHIN made its public debut in June 2005 at a media event at a seniors’ centre
in Grimsby. Shortly thereafter, it began the process of engaging the community
concerning issues relating to health services.

The Community Gets Engaged

47 During July and August 2005, the HNHB LHIN held introductory meetings with health
service providers, including their governors, to introduce the LHIN model and inaugural
LHIN leadership teams. These meetings were by invitation only. Open houses for the
general public were hosted by the LHIN Board Nominating Committee in September and
October 2005 to introduce the LHIN model and recruit interested applicants for the LHIN
Board. The LHIN was also busy during the fall and winter of 2005, recruiting staff, and
conducting various information sessions with community stakeholders. At its open houses
and sessions, the LHIN also solicited attendees’ views on health care in the community.

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
20
The LHIN uses these funds to support its planning, funding and integration roles, including community
engagement. While the April 1, 2007 – March 31, 2010 Accountability Agreement with the Ministry refers to
$4.028 million being allocated for this purpose, the LHIN advised that $5 million is actually used to operate the
LHIN.

11
“The LHIN Spin”
August 2010
! !

!
 48 In March 2006, the LHIN issued a document relating to community engagement, entitled
Our Commitment to you: Community Engagement for Health Care Planning & Decision
Making, in which it described community engagement as one of its core functions. The
document also refers to different levels of engagement, ranging from “informing” to help
the public understand issues, “consulting” to solicit feedback, “involving” the public to
ensure that public and private concerns are considered and understood, “collaborating” on
each aspect of the decision-making, to “empowering,” where decision-making is actually
placed in the hands of the public.

49 In developing its first integrated health services plan, the LHIN was guided by the
information provided by the Ministry’s System Integration Team concerning the priorities
it had identified through its community workshops in the fall of 2004. In addition to its
earlier open houses, meetings and information sessions, the LHIN held 14 open houses
throughout the community, where it discussed the priorities that had been identified and
received stakeholder views. Community comments were taken into consideration when
the LHIN prepared its draft Integrated Health Services Plan, which was released to the
public for comment through six open houses held in early fall 2006. The final plan was
published in November 2006. Integrated Health Services Plans are required to be
submitted every three years. The LHIN held community open houses in the fall of 2009
that focused on finalizing its plan for the next three years. The HNHB LHIN’s 2010-2013
Integrated Health Service Plan was issued in December 2009.

50 During our investigation, the LHIN advised that as part of its ongoing community
engagement, it periodically meets with MPPs and mayors in its catchment area, editorial
boards of local newspapers and other stakeholders. The LHIN attends various meetings
with community groups, the public and health service providers regarding the community
health care system generally as well as specific initiatives. It has indicated that all of these
contacts serve to inform its vision of providing the “right care, at the right place, at the
right time for community members.” LHIN officials suggested that community
engagement is an ongoing cumulative process – “a journey, not just an event.” We also
heard that “community engagement” was a very fluid concept, and could consist of an
informal phone call or even a casual conversation with someone in the community. Those
“being engaged” might not even be aware that their comments are being filed away for
later use in determining priorities and planning for local health services.

51 Citizens can contact the LHIN in writing, by telephone, through its website, or through a
request for a speaker. The LHIN board does not accept public delegations at its meetings.
However, at least one of the LHIN’s current members expressed disagreement with this
limitation, and it is not a uniform practice amongst LHINs.21

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
21
The HNHB LHIN has suggested that any comment on the part of a Board member that is inconsistent with the
board’s adopted practice must have been made in their personal capacity, as it would otherwise be a breach of the
board members’ fiduciary duty. However, the Ombudsman’s interviews are conducted under the authority of the

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 52 While the Hamilton Niagara Haldimand Brant LHIN does send representatives to attend
meetings to which the LHIN is specifically invited, we were advised that the board does
not encourage board members to attend community consultation sessions arranged by
health service providers.22 The LHIN’s senior representatives consistently advised us that
the LHIN is responsible for community engagement from a “system” perspective, at the
“10,000-foot level,” in contrast to community engagement on specific restructuring plans,
which they generally viewed as the purview of the health service provider responsible for
developing the plan. We were told that the uninvited presence of the LHIN at a public
outreach event conducted by a hospital or other health service provider could interfere with
the service provider’s ability to engage the community effectively.

53 This belief is not shared by all LHINs in Ontario. We learned that a number of LHINs do
permit their board members to attend health service provider community sessions, as
observers. One senior official for another LHIN remarked that he found this practice very
helpful. He explained that in one case where a hospital had been asked by the LHIN to go
back and engage in more public sessions, when LHIN officials attended the events, they
found a significant discrepancy between what the hospital had advised the LHIN about the
community engagements it had undertaken and what LHIN members witnessed first-hand
at the additional sessions.

54 The 60-plus complaints that my Office received do not relate to the LHIN’s general
engagement of the public in relation to broad-based systemic planning and priorities.
Rather, it is the LHIN’s perceived failure to adequately “engage” the community with
respect to two specific initiatives that has led to a flurry of complaints to my Office. This
is not surprising. It is one thing to engage in blue-sky thinking and philosophical debate
about the future of health care in general. It is quite another when concrete proposals have
been put forward which may have a direct and significant impact on the services available
to citizens in the foreseeable future.

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Ombudsman Act, which all government officials are required to comply with. Our investigations take place in
private to encourage candor and to protect the integrity of our process. All interviews conducted during this
investigation were conducted with board members in their official capacity, in accordance with the provisions of the
Ombudsman Act.
22
However, the LHIN did advise that board members can attend such meetings in their personal capacity as citizens
of the community, and that it has recently clarified this to them.

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Hamilton Health Sciences “Access to Best Care” Plan
55 Hamilton Health Sciences is a multi-site corporation comprised of six hospitals and a
cancer centre.23 On January 15, 2008, Hamilton Health Sciences publicly announced its
“Access to Best Care” plan, or the “ABC” plan. The ABC plan proposed a number of
changes to health services delivery in the region, including the conversion of McMaster
Children’s Hospital at the McMaster University Medical Centre to a Pediatric Centre of
Excellence, the transfer of adult inpatient services to St. Joseph’s Healthcare and other
sites of Hamilton Health Sciences, and the creation of a new Urgent Care Centre.

56 The ABC plan indicates that it “was created with advice and guidance from a wide range
of stakeholders,” including Hamilton Health Sciences staff, physicians, directors, academic
leaders and partners in the health care system.

57 Hamilton Health Sciences held a series of open houses beginning in March 2008 to discuss
the proposed integration and its implementation. Many of the complainants to our Office
were highly critical of the consultation conducted by Hamilton Health Sciences. They
expressed the belief that by the time the plan was unveiled for comment, it was essentially
a fait accompli. They alleged that Hamilton Health Sciences was really only interested in
feedback on how to implement the changes and explain them to the public, not in obtaining
stakeholder views for the purpose of plan development.

58 Although the proposed changes could have a direct financial impact on Hamilton
Emergency Services (EMS) to the tune of about $1.5 million, Hamilton EMS advised us
that it had not been consulted during plan development, and only found out about plan
details the same day they were announced to the general public. Critics have suggested
that notifying the public after the fact of a fully formed plan is inconsistent with the
legislative requirement to “engage the community… when developing plans and setting
priorities for the delivery of health services.”

59 In accordance with the Act, the LHIN had an opportunity to review the ABC plan and to
consider the adequacy of the community engagement around it.

60 The ABC plan was a “voluntary” integration plan. Under the circumstances, Hamilton
Health Sciences was required to give notice of the proposal to the LHIN, which in turn had
60 days to consider the plan. The LHIN had the option within that time frame of issuing a
proposed decision to prevent the plan from proceeding. If it chose to go this route, this
would trigger a 30-day public right to make written submissions concerning the plan,
followed by another 30-day period to allow the LHIN to consider the submissions and

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
&'! These
are:!Hamilton General Hospital, Chedoke Hospital, Henderson General Hospital, Juravinski Cancer Centre,
McMaster Children’s Hospital, McMaster University Medical Centre and St. Peter’s Hospital.!

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 reach a final decision. Alternatively, the LHIN could allow the 60 days to pass without
issuing a decision, which would result in Hamilton Health Sciences having the go-ahead.

61 In considering whether to issue a decision forestalling a voluntary integration plan, a LHIN

must consider the public interest, the extent to which the integration is inconsistent with
the Integrated Health Service Plan, and any other matter that it considers relevant. 24

62 The ABC plan was officially submitted to the LHIN on August 6, 2008, and it was
discussed at a public LHIN board meeting on August 26, 2008. The minutes of this
meeting indicate that LHIN staff presented a summary of the key features of the plan and
explained the LHIN’s role with respect to the review and approval of the plan.

63 The LHIN did not specifically invite public comment after receiving the ABC plan for
review, but this did not stop citizens from continuing to express concern about the ABC
proposals. However, the approximately 40 written submissions from municipal
councillors, residents and health care professionals that did make their way directly to the
LHIN were rerouted to the corporate hospital board of Hamilton Health Sciences for
consideration.

64 On September 12, 2008, Hamilton city council formally wrote to the LHIN, requesting that
it conduct community engagement on the full ABC plan before making its decision. In a
September 24, 2008 response, the LHIN advised that until its board had an opportunity to
discuss and/or debate the plan, any commitment to further consultation would be
premature. However, five days later, the LHIN board considered the ABC plan for the last
time.

65 At a board meeting on September 29, 2008, the LHIN viewed a multimedia slide
presentation on the ABC plan, which highlighted the roles and responsibilities of the LHIN
and of hospitals, identified the problems that the ABC sought to address and its proposed
solutions, explained how the proposed changes were in keeping with the public interest,
and outlined the options of the board regarding the plan. Two of the 51 slides that were
presented contained a very brief summary of concerns raised by the community on the
plan, including criticism of the extent of public consultation that had been undertaken.
After this presentation, the LHIN board passed a unanimous decision, finding that it was in
the “public interest not to issue a decision ordering the parties not to proceed with the
integration” – effectively allowing the ABC plan to proceed.25

66 The following day, a LHIN board member, who had been prevented from considering the
plan as a result of a conflict of interest, resigned. In his public letter of resignation, he
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
&#!Local Health Services Integration Act, supra note 3, s. 27(7).
25
While the LHIN could have remained silent about the merits of the Plan, it has adopted a practice, where it
decides not to prevent a voluntary integration plan, of making a definitive statement in support of the plan.

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 criticized the board’s decision-making process, the lack of public input into the plan and
the lack of attendance by LHIN board members at community meetings held by Hamilton
Health Sciences to discuss the plan.

67 As the ABC plan was a voluntary integration, and the LHIN did not propose to prevent it
from being implemented, there was no formal public right under the Local Health System
Integration Act, 2006 to make submissions on the plan before a final decision was arrived
at. However, the distinction between an integration required or restrained by the LHIN,
and a voluntary integration that proceeds unabated, was lost on many members of the
community, who could not understand why the LHIN had not allowed them an opportunity
to be heard on the substance of the plan. Given the general intent behind the Local Health
System Integration Act, 2006, of allowing health service decision-making at the grassroots
level, many citizens – not unreasonably – expected that they would be afforded the chance
to voice their views on the specific plan proposals before any decision was made. They
were understandably confused and disappointed when the LHIN gave the ABC plan the
green light on September 29, 2008 without permitting additional community input.

68 Many of the people who complained to our Office criticized the lack of community
engagement undertaken by both Hamilton Health Sciences and the LHIN with respect to
the ABC plan. Some suggested that the LHIN did not fully consider their comments, as
they were essentially “filtered or sterilized” by LHIN staff in the multimedia presentation.
Local media also highlighted concerns with respect to the plan proposals, which many
found controversial, as well as the sufficiency of community engagement.

69 During our investigation, LHIN officials explained that it was up to Hamilton Health
Sciences to engage the community around the ABC plan, and that LHIN board members
were accordingly discouraged from attending Hamilton Health Sciences’ open houses
where the plan was discussed. While LHIN officials acknowledged that they do have a
role in ensuring that a health service provider conducts stakeholder outreach, they stated
that they relied on and trusted the information provided by Hamilton Health Sciences
concerning its efforts to obtain public input. In response to public pressure, the LHIN did
obtain a long list from Hamilton Health Sciences of the consultations it had undertaken,
but did not request any additional documentation on the results of the hospital’s public
outreach. It is not clear whether the hospital would have been in a position to produce
documentation recording public feedback had the LHIN actually asked for it. The
Hamilton Spectator reported that it had inquired into the public response that had been
obtained by the hospital during its open houses. The hospital apparently advised the
newspaper that the results of the outreach were recorded in the form of personal and
mental notes and had been the subject of debriefing conversations held after the open
houses had taken place.26

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
&$! Dana Brown "No rules on input for HHS plan" The Hamilton Spectator (16 January 2009) A4.!

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 70 Senior LHIN officials told us that the LHIN did not engage in its own community
consultation because it would have been unlikely to elicit any “new information.”
However, one LHIN board member advised us that he had personally conducted
community engagement before casting his vote on the ABC plan. He explained that he
had engaged citizens at his golf club, in shopping centres and in line for groceries about
their views about creating a dedicated children’s hospital. Based on his personal straw
poll, he felt that the majority of citizens would be in favour of the proposed integration.

71 In addition to raising concerns about the quality of community engagement surrounding

the ABC plan, complainants also questioned how the LHIN board could make decisions on
such a major plan after very limited discussions at two public meetings. The LHIN chair
and other LHIN representatives explained that it often holds “education sessions” in
addition to public meetings at which additional information is obtained and discussed.
LHIN officials advised us that the LHIN had discussed the ABC plan on a number of
occasions behind closed doors, even before it had been formally presented with the plan.
During an “education” session on March 27, 2008, the board discussed the hospital’s
potential voluntary integration, and on April 8, 2008, senior officials from Hamilton Health
Sciences made a presentation to the board concerning its proposals. On July 8, 2008, the
board discussed the Hamilton Health Sciences Capital Plan – which included reference to
the hospital’s Master Planning and Access to Best Care – in a closed session. On
September 23, 2008, representatives from St. Joseph’s Healthcare made a private
presentation to the board concerning urgent care centres like the one proposed in the ABC
plan.

72 Another hospital restructuring plan had also been causing waves in the community,
sparking calls for greater opportunities for public participation. This plan involved a
proposal for a large-scale overhaul of health services in the Niagara region.

Niagara Health System “Hospital Improvement Plan”

73 The Niagara Health System is the largest multi-site hospital amalgamation in Ontario. It
comprises seven sites,27 serving approximately 434,000 residents across the 12
municipalities that make up the Regional Municipality of Niagara.

74 Like other hospitals, Niagara Health System is required, as a term of its service
accountability agreement with the LHIN, to maintain a balanced budget. The hospital had
failed to achieve a balanced budget under the 2007-2008 service accountability agreement.

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
&(! Douglas Memorial Site in Fort Erie, Greater Niagara General Site in Niagara Falls, Niagara-on-the-Lake Site,
Ontario Street Site in St. Catharines, Port Colborne Site, the St. Catharines General Site and the Welland Hospital
Site.

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 On May 20, 2008, the LHIN board held a special meeting to consider what to do about the
hospital, which by then had been running a deficit for 2007-2008 and had projected a
deficit for 2008-2009 of close to $18 million. The LHIN determined that Niagara Health
System would have to submit a “Hospital Improvement Plan” or HIP, which would then be
used to inform the 2009-2010 service accountability agreement. On May 30, 2008, the
LHIN formally notified the hospital of this decision. While the service accountability
agreement entitled the LHIN to require the hospital to produce a plan within 30 days, the
LHIN allowed the hospital until July 15, 2008 to submit its proposal. The LHIN also
advised the hospital that it should include information in its submission about the
community engagement informing the creation of the plan, but noted, “It is not expected
that additional community engagement between receipt of this letter and submission of the
HIP to the LHIN be carried out.”

75 During our investigation, LHIN officials explained that the Niagara Health System had
undergone nine reviews in the previous decade, and the LHIN anticipated that the plan
would rely on the information that had already been gathered as a result of those reviews.
The LHIN also retained an expert adviser, who had experience in amalgamating and
running a multi-site hospital in Ottawa, to comment on the merits and feasibility of the
plan developed by the hospital. The LHIN’s expert adviser was expected to carry out
community engagement on behalf of the LHIN as part of his mandate.

76 Mindful of its obligations under the Local Health Services Integration Act, 2006 (LHSIA),
on June 23, 2008, the Niagara Health System’s Chief Executive Officer sent an email to
the LHIN, enclosing a briefing note concerning, among other things, community
engagement, which commented:

…LHSIA provides no details regarding the extent of the engagement to be

undertaken by hospitals nor have the courts yet provided any guidance. It is the
opinion of our legal counsel, [… ] , that given the materiality and the easily
understood nature of some of the changes contemplated as being included in the
Improvement Plan, a court would likely expect a robust level of consultation to
occur before the hospital board made a firm commitment to implement such a
plan. This would likely include one or more public meetings, something that is
not possible in the time available. […]

The NHS, due to time constraints, will not be in a position to conduct community
engagement on the specifics of the HIP, prior to the board meeting of July 15,
which is the same day the HIP is due to the LHIN. Accordingly, the HIP should
be submitted subject to future consultation to be engaged in by NHS in order to be
in compliance with LHSIA.

77 Despite its reservations concerning the ability to engage the public on such short notice,
the hospital did undertake some attempts to gauge community views. For instance, on
June 26, 2008, the hospital wrote to the LHIN, indicating that a new section of its external
website would be going live that day. It explained that this section featured information

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 and “educational material with a series of questions to seek feedback from the community
regarding how services can be delivered differently to inform the HIP submission.”

78 On July 15, 2008, Niagara Health System submitted its Hospital Improvement Plan to the
LHIN.

79 The LHIN’s expert adviser and his team then held community consultation meetings in
Fort Erie, Niagara Falls, St. Catharines, and Port Colborne to discuss the plan with
stakeholders. LHIN staff and board members also attended these meetings to observe.
Meetings were also held with Niagara Emergency Services, transit leaders, business and
philanthropic leaders, and the mayors and councillors of affected communities. The LHIN
received 155 submissions and complaints concerning the hospital improvement plan,
including a 14,000-signature petition from Fort Erie residents. Fort Erie was particularly
vocal regarding its concerns about the plan. At the community consultation meeting held
there, more than 5,000 residents showed up to oppose the plan.

80 The HIP generated considerable public interest, including strong criticism from many
stakeholders about the consultation process. In an attempt to dispel some of the confusion
about community engagement, the LHIN chair wrote a letter to the editor that appeared in
the St. Catharines Standard on September 2, 2008. In that letter, she explained:

The LHIN will receive [its expert adviser’s] recommendations on the plan … on
October 28… At the same time, the NHS continues to receive feedback on its
plan from the communities it serves and the stakeholders it works with. The NHS
is developing a report that identifies issues and options proposed by individuals
and communities. These findings will be an addition to the plan and will be
provided to the review team. The deadline for inclusion in this report is Monday,
Oct. 6. … Ideas as to how communities can advance the implementation of the
plan and the role they are willing to undertake will be welcome advice to the NHS
and the review team.28

81 At a board meeting on October 28, 2008, the LHIN received its expert adviser’s report and
recommendations on the plan. The board forwarded the report on to the hospital, with the
direction that it be considered along with the hospital’s consultation in the preparation of a
final Hospital Improvement Plan.

82 The Niagara Health System prepared an amended plan, which was provided to its
Community Standing Committees for approval. The Fort Erie Community Standing
Committee refused to approve the HIP, which included a proposal to convert the Douglas
Memorial site to a 24/7 urgent care centre. While the hospital’s board of directors did not

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
&)!“Input
important in Hospital Improvement Plan,” Letter to the Editor, The St. Catharines Standard (2 September
2008) A6.!

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 consider the Standing Committee’s position to be unreasonable, it determined that it would
continue to advocate for the implementation of the HIP at all of its sites, including Douglas
Memorial. Accordingly, the hospital submitted its amended plan to the LHIN on
November 19, 2008.

83 At a LHIN board meeting on November 25, 2008, the LHIN asked the hospital to remove
those elements of the HIP relating to Fort Erie, so that the LHIN could better assess the
implications with respect to the Douglas site. In accordance with this direction, the
hospital provided the LHIN with an updated plan on December 10, 2008.

84 On December 16, 2008, the LHIN board considered the HIP yet again. At that meeting,
the LHIN decided to direct that the Douglas site be converted into an urgent care centre,
and that the changes necessary to accomplish this be reflected in the plan.

85 In accordance with the Act, the public was given a 30-day period during which additional
submissions could be made regarding the LHIN’s proposed integration decision. At the
end of this period, the LHIN confirmed its decision.

86 The Hospital Improvement Plan attracted considerable local controversy. In its

consultation summary report, the hospital acknowledged that there had been criticism from
some stakeholders concerning the sufficiency of public consultation about the plan, which
it attributed to the short time frame for development set by the LHIN. In his report, a
member of the expert adviser’s team noted that the short time frame to produce the plan
left little time for broad consultation and suggested that there was a “price to pay” for
limited consultation.

87 Once again, we received complaints concerning the fact that the LHIN board only
considered the HIP in a few open meetings and decisions were made after limited public
discussion, leaving citizens uncertain as to the basis for the board’s decision-making. It
was alleged by some complainants that at one open meeting, board members asked many
questions that were not answered. They wondered how a decision could be made with
significant information still outstanding. However, we were told by a LHIN official that
answers were eventually obtained in a closed “education” session and that they were later
discussed in an open board session. The LHIN has also indicated that answers were
provided on its website.

88 As in the case of the ABC plan, the LHIN board advised us that it had held private
“education” sessions to consider additional information pertinent to its decision-making.
Even before it directed that the Niagara Health System prepare a Hospital Improvement
Plan, on April 8, 2008, the board met with representatives of the hospital to discuss the
previous reviews that had been conducted. Once the planning had begun in earnest, the
Chief Executive Officer of Niagara Health System met privately with the board on June
10, 2008, and again on July 7, 2008, to make presentations, which included discussion of
HIP proposals. On August 8, 2008, the board met in camera to discuss a number of issues
relating to the Niagara Health System, including the Hospital Improvement Plan, and on

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 August 25, 2008, the board met privately with its expert adviser and his review team. On
November 18, 2008, the LHIN board held a closed meeting in which it considered the
plan, and also listened to presentations by Niagara Emergency Services and the mayors of
Port Colborne and Fort Erie, in which they highlighted their issues and concerns with the
plan. Finally, on December 9, 2008, the board conducted a private video conference with
its expert adviser.

89 To add to the public perplexity surrounding community engagement by the LHIN, in the
case of the Niagara Health System Hospital Improvement Plan, it did take part in
community outreach in a much more direct way than in the case of the ABC plan. LHIN
officials explained that while the LHIN does not generally interfere in the community
outreach undertaken by health service providers, the Hospital Improvement Plan had been
taken at its initiative and proposed extensive changes to the health services to be provided
to residents, while the ABC plan was a voluntary initiative and only involved relocation of
services. Unfortunately, these differences were not necessarily obvious to the LHIN’s
stakeholders and community members.

90 During our investigation, the LHIN chair acknowledged that one of the lessons that she
had taken away from her experience with the Hamilton Health Sciences ABC plan was that
all the work that the board undertook to prepare for its deliberations – including the
conversations held with local politicians where support for the plan was privately
expressed – should have been made available to the public. She indicated that this learning
was applied in the deliberations related to the Niagara Health System HIP decision-making
process. LHIN staff also advised us that the LHIN’s practice has changed and that now
when staff summarizes community feedback, a paragraph from each submission is
included to give board members a better flavour of citizen concerns.

91 While the LHIN has more recently made efforts to improve the openness of its process, it
is clear that significant improvement is required to ensure that community engagement is
not just a superficial afterthought, but a genuine and material exercise that assists and
informs LHIN decision-making.

Rules of Engagement
92 As illustrated by the experience of the Hamilton Niagara Haldimand Brant LHIN, there is
considerable uncertainty about what constitutes community engagement under the Local
Health System Integration Act, 2006. While there is some value in allowing for a flexible
process that can be adapted to satisfy local differences, there is also a need for greater
definition of what is a founding principle of the LHIN system.

93 At a minimum, stakeholders need to know what and what not to expect from health service
providers and LHINs when it comes to community engagement. There should be some

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 basic and consistent ground rules. It should be clear at what stage of the planning process
community engagement should take place, and that it is taking place. Community
engagement should not happen by surprise or ambush. Stakeholders should know that
their views and comments are being sought as part of a community engagement process.
They should be given sufficient information about the issue under consideration to allow
them to take part in informed discussion. Adequate records of community outreach should
also be kept and made available to ensure that stakeholder views are accurately
represented. Little weight can be placed on stakeholder views that are obtained in
circumstances where stakeholders don’t fully realize the reason why their views are being
solicited and the purpose to which they will be put.

94 Community engagement should also strive to reach a large cross-section of the stakeholder
community. It should not be arbitrary or elitist. Everyone should have an equal
opportunity to voice his or her views on the future of local health services. Participation
should not be dependent on whether a resident can afford to golf at the same club as a
LHIN board member or happens to shop at the same stores. While casual conversations
with community members will undoubtedly always take place and should not necessarily
be discouraged, they should not be seen as satisfying a LHIN’s legal obligation to engage
the community with respect to regional health services decisions.

95 The Ministry has an overarching responsibility for the administration of the Act. In order
to fulfill this responsibility, it should take the lead to ensure that community engagement
surrounding local health services is robust and real, by helping to establish some basic
general standards.

96 In the case of the Hamilton Niagara Haldimand Brant LHIN, the LHIN should also use its
website, meetings and other methods to educate the community about its general practices
relating to community engagement, as well as the nature of engagement to be expected
with respect to general systems planning and specific plans under consideration –
including clarifying the relative roles of health service providers and the LHIN.
Stakeholders will continue to be frustrated unless they are encouraged to develop more
realistic expectations of their role in decision-making about local health services.

97 In order to engender greater public confidence and comply with the principles of openness
and transparency underscoring the Act, the LHIN must also immediately abandon its
practice of holding closed meetings for educational purposes. The LHIN board’s practice
of holding private “education” sessions is a clear contravention of the Act. There is no
exception allowing for the board to meet behind closed doors for this purpose. The
LHIN’s By-law 2, to the extent it attempts to redefine “meeting” to exclude educational
sessions, is of no force and effect. Its by-law cannot override the statutory requirement
mandating open meetings.

98 Had the Legislature intended for LHINs to have the ability to meet in secret for the
purposes of education, the Act would have said so. Since 2007, under amendments to the
Municipal Act, 2001, municipalities have had the express statutory authority to hold

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 education and training sessions in certain circumstances, provided procedural requirements
have been met and at the meeting no member discusses or otherwise deals with any matter
in a way that materially advances the business or decision-making of the municipal body
holding the meeting. Quite properly, there is no similar exception applicable to the LHINs.
In the context of decision-making about local health services, private educational sessions
are completely inconsistent with the intent of the Act, including its emphasis on
community engagement. By its admission, the board often conducts these sessions to
obtain information and clarify matters in connection with specific plans under its
consideration. In such circumstances, these sessions are not purely educational exercises,
but activities directed at moving the deliberative process forward. Similar closed meetings
would not be sanctioned under the Municipal Act, as they are clearly being held for the
purpose of materially advancing business and decision-making. In the LHIN context, this
is the very type of conduct that the Act contemplates will take place in full view and with
the full knowledge of the public.

99 While the LHIN may have been well-intentioned in holding its “education” sessions, these
meetings were plainly illegal. It is not surprising that stakeholders were left confused and
frustrated by the engagement process when they were left out in the dark about matters
directly informing the LHIN’s decision-making.

100 LHINs must make difficult and sometimes unpopular choices about health services. They
will never please everyone. However, I believe that the public response to the Hamilton
Niagara Haldimand Brant LHIN’s recent consideration of two plans illustrates the danger
of following practices that undermine openness and transparency, and in doing so, attract
public suspicion and conjecture.

Opinion
101 The Hamilton Niagara Haldimand Brant Local Health Integration Network’s failure to
follow and ensure that health service providers followed a clear and transparent process of
community engagement in relation to its consideration of the Hamilton Health Sciences
Access to Best Care Plan and the Niagara Health System Hospital Improvement Plan was
based, in part, on lack of clarity in the Local Health System Integration Act, 2006, which is
unreasonable, in accordance with s.21(1)(b) of the Ombudsman Act.

102 The Hamilton Niagara Haldimand Brant Local Health Integration Network’s failure to
ensure that the community was adequately educated around the community engagement
process was also unreasonable and wrong, in accordance with ss.21(1)(b) and (d) of the
Ombudsman Act.

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103 Finally, the Hamilton Niagara Haldimand Brant Local Health Integration Network’s
practice of holding closed education sessions is contrary to law, in accordance with s.
21(1)(a) of the Ombudsman Act.

Recommendations
Accordingly, I am making the following recommendations:

Recommendation 1
The Ministry of Health and Long-Term Care should take all steps necessary to prepare and put
forward guidelines setting out basic standards to be met by health service providers and Local
Health Integration Networks when conducting community engagement under the Local Health
System Integration Act, 2006.

Subsection 21(3)(b) Ombudsman Act

Recommendation 2
The Hamilton Niagara Haldimand Brant Local Health Integration Network should take all steps
necessary to educate the community about its general practices relating to community
engagement, as well as the nature of community engagement to be expected with respect to
systems planning and specific integration plans, including clarifying the relative roles of health
service providers and the Local Health Integration Network.

Subsection 21(3)(b) Ombudsman Act

Recommendation 3
The Hamilton Niagara Haldimand Brant Local Health Integration Network board of directors
should immediately amend its By-law 2 to comply with the open meeting requirements of the
Local Health System Integration Act, 2006 and cease its practice of holding closed educational
meetings.

Subsection 21(3)(b),(g) Ombudsman Act

Recommendation 4
The Ministry of Health and Long-Term Care and the Hamilton Niagara Haldimand Brant Local
Health Integration Network should report back to my Office at quarterly intervals on their
progress in implementing my recommendations until such time as I am satisfied that adequate
steps have been taken to address them.

Subsection 21(3)(b),(g) Ombudsman Act

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Responses
104 At the conclusion of my investigation, a preliminary report and recommendations were
provided to both the Hamilton Niagara Haldimand Brant Local Health Integration Network
and the Ministry of Health and Long-Term Care for their review and comment.

Ministry Response
105 On August 24, 2009, the Ministry of Health and Long-Term Care responded to my
preliminary report and recommendations. The Ministry acknowledged that the
government would always have the ultimate responsibility for providing Ontarians with
high-quality, accessible health care services, and indicated that as Crown agencies, LHINs
work in partnership with the Ministry to ensure that unique local health care needs and
priorities are addressed.

106 The Ministry supported my recommendation for greater clarity and transparency on
community engagement and undertook to work with the LHINs to strengthen community
engagement obligations under the jointly negotiated Ministry-LHIN Accountability
Agreement (Recommendation 1). The Ministry noted that it had already worked with the
LHINs to develop Engaging with Impact: Targets and Indicators for Successful
Community Engagement by Ontario’s Local Integration Networks, a document that
proposes a series of recommendations and indicators that can be used to assess
performance and strengthen community engagement between the LHINs, providers and the
public. The Ministry also advised that it was working with three LHINs (North West,
South East and Central) to develop a strategy for disseminating this information to all
LHINs.

107 The Ministry also supported my recommendation for the Hamilton Niagara Haldimand
Brant LHIN to ensure that it educate its community about engagement with respect to
system planning and integration (Recommendation 2). It committed to communicate this
expectation to the HNHB LHIN and all LHINs to ensure better understanding across the
province regarding community engagement.

108 In addition, the Ministry undertook to work with all LHINs to clarify expectations
concerning public board meetings (Recommendation 3). Finally, the Ministry agreed to
report back to my Office twice a year over the next two years regarding its progress
(Recommendation 4).

109 On June 22, 2010, our Office obtained an update from the Ministry on the steps that it had
taken in response to my recommendations since receiving my preliminary report. We were
advised that LHIN and Ministry representatives had been involved in a working group
directed at developing core principles relating to community education and best practices.
We were told that while the guidelines were not yet finalized, in future the LHINs will be
expected to develop a yearly community education plan, evaluate participant awareness

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 through surveys at the end of community education activities, and report to the LHIN
boards the community input that has been received. The guidelines will be reviewed
annually by a Community Engagement Network, which will update them based on
feedback and new information. In addition, each LHIN will establish an evaluation
committee composed of external and internal LHIN resources to review community
engagement practices to ensure the LHINs are meeting best practices expectations.

110 The Ministry also advised that it has retained a consultant to meet with the LHINs to
address good governance and has been working with the LHINs on the development of a
good governance guide. In addition, it met with the HNHB LHIN and emphasized that the
LHIN should not be making decisions during in camera meetings, unless specifically
provided for in the exceptions to the open meeting requirements, and that it should be more
explicit about what it has done in open board meetings.

111 On June 22, 2010, the Ministry advised that it was of the view that the LHIN’s By-law 2
allowing closed meetings for the purpose of “education” was consistent with the intent of
the Local Health Services Integration Act. We were told that from the Ministry’s
perspective, the Act only requires that a LHIN board meet openly if it is actually making a
decision.

112 I find this flip-flop by the Ministry to be particularly troubling. The requirement for
LHINs to hold open meetings is a very significant part of the LHIN process. In respect of
open meetings at the municipal level, it has been said:

The democratic legitimacy of municipal decisions does not spring solely from
periodic elections, but also from a decision-making process that is transparent,
accessible to the public, and mandated by law.
– Hon. Madam Justice Louise Charron, Supreme Court of Canada

113 It is a very serious matter to close a LHIN board meeting to the public. The Act expressly
sets out only 11 exceptions to the open meeting requirement and prescribes procedural
steps that must be followed before a meeting can be closed. Before closing a meeting, a
public vote must first be taken, and the nature of the matter to be considered at the closed
meeting as well as the general reasons why the public is to be excluded must be clearly
stated.

114 If the Legislature had intended for there to be another exception to the open meeting
requirement for “education” sessions it surely would have said so, as it did in the recent
amendment to the Municipal Act. The open meeting requirements are remedial and
intended to be interpreted broadly, consistent with the public interest in transparency and
accountability. The only provisions that are to be narrowly interpreted in this context are
those providing for exceptions to the general rule that meetings should be held openly.
Accordingly, the open meeting requirements in the Local Health System Integration Act
should be construed expansively in the public interest rather than improperly constricted
for the sake of the LHIN’s convenience. There is simply no exception in the Act that

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 would permit this type of closed session to occur, nor should there be.

115 I fully agree with the proposition that not all gatherings of the LHIN board of directors will
be meetings that should attract the requirement that they be held open to the public; for
example, a purely social gathering where no discussion takes place relating to the LHIN’s
operations would not trigger this obligation. The working definition of “meeting” that I
have adopted in the context of municipal open meetings recognizes that, at times, members
of an organization will meet in informal circumstances in which there is no need for the
public to be present to ensure the “democratic legitimacy” of the organization’s operations.
I consider that a “meeting” has taken place if members of the body come together for the
purpose of exercising their power or authority or for the purpose of doing the groundwork
necessary to exercise that power or authority. Gatherings of the LHIN board of directors
(or meetings with other entities) held to educate members about matters relating to the
exercise of their authority would certainly come within this definition. There is no
compelling policy reason to hold these meetings privately; quite the opposite. Any
meeting at which matters are discussed that might have a bearing on a future decision or
exercise of LHIN authority should be held openly, unless the subject matter to be
considered comes squarely within the statutory exceptions.

116 My investigation revealed that while considering the ABC plan, the LHIN board of
directors met on at least four occasions in private “education” sessions without notice to
the public to discuss matters related to the integration – sometimes hearing representations
from health service providers. In the case of the Niagara Health System Health
Improvement Plan, the board met behind closed doors at least seven times – sometimes
with health service providers and specific stakeholders. These meetings were patently held
for the purpose of doing the groundwork necessary to exercise the authority of the LHIN.
This is the very type of meeting that the legislation intended to keep open to the public.

117 Even the education exception applying to municipal meetings does not allow closed
sessions to take place that materially advance business or decision-making. It is not just
the actual decision-making that must be open, but also the sessions in which information is
obtained and considered leading up to that decision. Unless this process is open, the
decision may be transparent, but the reasoning behind it will remain opaque and the public
will be left confused, frustrated and dissatisfied.

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118 I believe the Ministry’s position regarding the LHIN practice of holding closed educational
meetings is antithetical to the community engagement principles in the Act, wrong in law,
and perpetuates a disservice to the people of Ontario, who are entitled to know how
decisions affecting community health care are arrived at. The Deputy Minister, in his July
15, 2010 letter, noted that the Ministry is continuing to review the concerns raised by my
Office about “educational meetings” and has undertaken that the Ministry “will be taking
action to clarify educational meetings and enhance the already extensive regulatory
framework designed to foster openness and transparency.” I strongly encourage the
Ministry to reconsider its position with respect to the open meeting requirements in the
Act.

LHIN Response
119 Unfortunately, the response received from the Hamilton Niagara Haldimand Brant LHIN
was also not particularly encouraging. !

120 The Hamilton Niagara Haldimand Brant LHIN’s response to my preliminary report and
recommendations was received August 25, 2009. The LHIN provided an 11-page, detailed
critique of my report, including factual clarifications and even stylistic suggestions, some
of which have been incorporated into this final report. The LHIN did not acknowledge any
failings with respect to the community engagement process, and it rejected the conclusions
that I had drawn and the recommendations that I had made concerning its community
engagement efforts and the conduct of board meetings.!

121 The LHIN took issue with many of my findings. For instance, the LHIN disputed my
reference to there being no minimum standards for community engagement, suggesting
that this conclusion contradicted references in the report to specific provisions of the Local
Health System Integration Act, 2006. It stated that the statutory obligations were “not open
to interpretation” and assumed “that the Ombudsman intended to observe that in some
circumstances, LHINs may do community engagement beyond their minimum
obligations,” which it considered, “entirely reasonable as the evidence provided to the
Ombudsman indicates that the scope and content of community engagement will vary
depending on the purposes for the engagement and the community.”

122 As the LHIN pointed out in its response, the Act does set out an obligation on the part of
LHINs to engage the community with respect to the local health system, including when
establishing priorities, and indicates that certain groups must be consulted in this process.
It also suggests some methods that can be used for community engagement. In addition, in
certain cases, a right to make formal written submissions arises. Health service providers
are also required to engage the community when developing plans and setting priorities.
However, the provisions concerning community engagement are very general in nature. I
remain of the view that there are no clear and consistent standards as to what constitutes

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 community engagement or guidelines as to how it should be accomplished. This position
is consistent with the information we received from a Ministry official during the
investigation, who advised that the community engagement provisions in the Act had been
deliberately drafted in broad terms to enable them to be adapted to local needs. In
responding to my report, the Ministry did not dispute my observation that there is a lack of
definition surrounding community engagement, and – more importantly – it has
undertaken to take steps to achieve greater clarity and transparency with respect to the
community engagement efforts of both health service providers and LHINs.

123 From its response, it appears that the LHIN did not fully grasp the implications of my
opinions and recommendations. With respect to my concerns about the LHIN’s failure to
follow a clear and transparent process of community engagement, and my recommendation
(Recommendation 1) that the Ministry provide better guidance in this area, it commented:

While the LHIN understands that it may be the Ombudsman’s opinion that the
statutory obligations are insufficient, this is very different from it being the
Ombudsman’s opinion that the LHIN failed to fulfill its obligations. There is no
evidence in the report, nor would we expect in the record, that supports an opinion
or finding that the LHIN acted improperly or contrary to law in respect of
community engagement. If this LHIN is reading this aspect of the Report
correctly, the LHIN asks that the Report make it very clear that it is the
Ombudsman’s opinion that the legislation is lacking, not the actions of the LHIN.

124 For the benefit of the LHIN, I would like to make it clear that while I believe that greater
precision in the legislation would certainly have assisted, and that the lack of standards for
community engagement was definitely a problem, I believe that the LHIN had an
independent responsibility to ensure that community engagement was conducted in a
manner that was open and transparent. Consistent with the accountability relationship
existing between the LHIN and health service providers, it was incumbent on the LHIN to
take adequate steps to ensure that the community engagement conducted by health service
providers relating to local health services planning and priorities was compliant with the
spirit of the Act and service accountability agreements. In my view, there is sufficient
evidence documented in this report to suggest that the LHIN’s conduct with respect to
community engagement was deficient.

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125 As I have noted elsewhere in this report, I did not investigate the community engagement
efforts of the health service providers involved in the integration plans considered in this
investigation, and have consequently made no findings relating to the adequacy of the
community engagement that they conducted. However, it is evident that in the case of the
HNHB LHIN, it was largely content to rely on the word of health service providers as to
the degree of community engagement they had conducted. No formal records relating to
community engagement were required to be kept, and there was no scrutiny by the LHIN
of the results of outreach efforts on the part of health service providers. It was only in
response to public concerns that the LHIN actually requested a list of consultations that
had been carried out in relation to the Hamilton Health Sciences Access to Best Care Plan.
In the case of the Niagara Health System Hospital Improvement Plan, the health service
provider itself expressed concern about the adequacy of community engagement – and the
LHIN’s expert advisory team recognized that there had been limited consultation, given
the short time frame set by the LHIN.

126 In recognition that there is a systemic element to this issue, and other LHINs throughout
Ontario would undoubtedly benefit from a broader remedy, the most direct route to solve
this problem was to enlist the Ministry’s assistance in ensuring greater clarity, consistency
and transparency around the community engagement obligation. I am pleased that the
Ministry appears to understand this aspect of my report and has undertaken to work with
all Ontario LHINs to address it.

127 In its response, the LHIN also questioned my opinion and recommendation related to the
need to educate the public about the nature of community engagement (Recommendation
2). It remarked:

The LHIN understands that this recommendation arises because some or all of the
60 complainants appear to have indicated to the Ombudsman that if they had
understood the scope of the community engagement better, they would not have
made the complaint. In short, the complaint was not about the nature of the
decision, or even access to the process, but rather a lack of understanding of the
legislation. If this is a fair conclusion to draw from the Report, the LHIN would
ask that the Ombudsman review the Report and remove any tone, word usage, or
statement that implies or would allow a reader to reach an alternate conclusion.

128 The LHIN reviewed the community engagement activities that it had undertaken with
respect to both the Hamilton Health Sciences Access to Best Care Plan and the Niagara
Health System Hospital Improvement Plan, and noted:

Given its current comprehensive approach to community engagement, it would

help the LHIN to evaluate and improve its processes as well as target the
educational effort the Ombudsman is seeking, if the LHIN better understood the
gap that the Ombudsman’s recommendation is trying to address.

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 The public evidence and that collected by your office, reflects the LHIN’s
appreciation of community engagement as a “genuine and material exercise,
which assists and informs LHIN decision-making.” It does not reflect a belief
that community engagement is … “just a superficial afterthought.” To state
otherwise… is simply wrong and an extraordinary disservice to the staff, board
members and community of the LHIN. The LHINs are … still learning how to
fulfill [their] obligations in an effective and efficient manner and this LHIN
practices continuous improvement. If you are not merely recommending that the
LHIN educates the public on the legislation, it would be of great value to us to
understand how the community engagement processes and opportunities in
respect of the more recent NHS integration were unreasonable or otherwise
deficient.

129 My investigation revealed that the LHIN failed to adequately educate the public about the
nature of community engagement that was to be expected with respect to specific
integration plans under consideration. The HNHB LHIN did not clearly distinguish the
difference between community engagement at the health service provider level and at the
LHIN level. In the case of the Niagara Health System Hospital Improvement Plan, the
LHIN had to write a letter to the editor of a local paper to try to dispel some of the
misunderstandings and concerns that were circulating. Many who complained to our
Office were left frustrated, confused and dissatisfied by the public consultation process. I
believe it is incumbent on the LHIN to recognize that it is responsible for ensuring that the
community is given sufficient information to understand the rules of engagement from the
outset.

130 With respect to my concerns about the closed “education” sessions held by the LHIN and
my recommendation that the LHIN amend its by law and cease its practice of holding
closed educational sessions (recommendation 3), the LHIN sought to justify its conduct by
virtue of the fact that it has the right to manage and control the board of directors and to
pass by-laws and resolutions for conducting and managing the affairs of the LHIN. It
observed:

Recognizing that it would not be reasonable to interpret the bare words of the Act
to require public notice of an incidental encounter of two or three board members
at a local coffee shop, or the presence of several board members on a golf course
as a board meeting, the Board took it on itself – as it is permitted to do – to
provide a definition for a board meeting that meets the spirit and intent of the Act.
It adopted a definition that incorporates the concept of which a board is properly
constituted for the conduct of business and what the conduct of business entails.
Specifically:

“Board Meeting” means a meeting of the Board for the purpose of making
a decision or recommendation, the taking of an action or the giving of
advice in respect of any matter within the Board’s jurisdiction. A meeting

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 of board members for social, educational or purposes other than
conducting [LHIN] business is not a Board meeting. Where the Board
Members attend a meeting held by another organization or entity, or visit
another organization or entity, the meeting will not be considered a Board
Meeting subject to this by law, unless the Board members will be making
a decision or recommendation, taking an action or giving advice to the
[LHIN] in respect of any matter within the Board’s jurisdiction.

131 As a matter of basic statutory construction, while the LHIN may issue by-laws dealing
with its board meetings, it cannot, in doing so, limit the application of its statutory
obligation to hold open meetings. The LHIN submits that not all gatherings are meetings
and its by-law permits it to meet in private as long as the LHIN board does not conduct
business. As I have already discussed with respect to the Ministry’s response, while not all
gatherings will attract the open meeting requirements, I believe that the closed “education”
sessions the LHIN purported to hold in relation to the Hamilton Health Sciences ABC plan
and Niagara Health System HIP were required by law to be held openly. In addition,
contrary to the LHIN’s position, these meetings were clearly held to address board
business. They were not held to simply train or educate board members generally and they
were certainly not social get-togethers. Despite this, the LHIN disputes my opinion that
the practice of holding closed educational sessions in connection with integration plans is
illegal and argues that its practice is “fully consistent with the full spirit and intent of the
legislation.”

132 The LHIN expressed the view that our opposing views about the legality of holding these
private sessions represent “a reasonable difference of opinion.” I disagree. This is not a
grey area. The law is not unclear or ambiguous. Despite its arguments to the contrary, in
which the Ministry appears to be complicit, I remain confident the LHIN has repeatedly
violated the statutory open meeting provisions of the Local Health System Integration Act,
2006. Unfortunately, the LHIN’s apparent failure to grasp the significance of its
transgressions, and its reluctance to alter its practice, do not bode well for the integrity of
the LHIN’s decision-making in future. Failure to ensure openness and transparency with
respect to the LHIN’s operations ultimately has the potential to completely undermine the
confidence of the local community.

133 The HNHB LHIN was critical of much of the content of my report, including the language
used and the analysis employed. It commented quite extensively on what were, in its view,
“inappropriate omissions, inadvertent innuendo and highly subjective, rather than objective
conclusions.” I found the LHIN’s response overtly defensive rather than introspective in
tone. For instance, while not “diminishing the importance” of the complaints I had
received, the LHIN emphasized that they did not represent “many” complaints, when the
number of citizens serviced by the LHIN was considered. It then proceeded to call on my
Office to provide a detailed breakdown of the complaints, including percentages, in
relation to the various issues of concern considered in my investigation. The LHIN also
questioned several references in the report that simply reflected the evidence obtained from

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 stakeholders and official government sources.

134 Finally, the LHIN ended its response by remarking:

The LHIN understands that the Ombudsman has concluded that there are a
number of areas in which improvement could be made. The LHIN also
understands that despite its best efforts, it will never be able to please everyone in
its community all the time. There will always be disagreements over what is in
the best interests of the LHIN as a whole and it will always be left to the LHIN to
make that decision. Constant improvement is a goal of this LHIN and the LHIN
welcomes constructive criticism and suggestion for improvement that will enable
it to improve the accessibility and acceptance of its decisions. To this end, the
LHIN does appreciate the spirit in which the Ombudsman’s recommendations are
made. Moreover, the LHIN respects the effort that was made by the Ombudsman
and in particular, the Ombudsman’s staff, to understand the LHSIA, the LHIN
and the difficult decisions that the LHINs are called upon to make with respect to
local health services.

135 Unfortunately, while the LHIN purports to welcome constructive criticism, I found its
response generally dismissive of my report and recommendations. The LHIN has not
accepted that any of my negative findings regarding its conduct are warranted or
undertaken to take any concrete steps to improve. While the Ministry acknowledges that
change is necessary to ensure the intent of the LHIN system is fully actualized, the
Hamilton Niagara Haldimand Brant LHIN appears to remain resolute in its conviction that
its conduct was beyond reproach, and seeks to place the onus on my Office to further
justify my concerns. The LHIN’s lack of insight is regrettable. Frankly, after receiving
this response, I was disappointed and worried that unless the LHIN adjusts its attitude and
its actions, trust in the LHIN will erode and the integrity of the LHIN system in its
community will be undermined.

136 On June 23, 2010, my Office spoke with Hamilton Niagara Haldimand Brant LHIN
officials, including the Chair, to obtain information on any initiatives it has undertaken
since responding to my preliminary report. At that time the LHIN advised that it had
enhanced its speakers bureau and had been talking with the public and community groups
about community engagement. It has also started including on its meeting agenda a
community engagement chart showing all of the community engagement it has conducted.
The LHIN has also added a standing item on the public meeting agenda entitled, “Report
of the board members on Community Engagement” and time is set aside at each public
meeting for any board member who may have participated in community engagement to
share information with the rest of the Board and the public. This could include discussions
that the member has had with people in shops, on the street or at more formal events.

137 The LHIN also advised that it has started to explore using social media to reach a greater
demographic and to educate the public about what it is doing in relation to community
engagement. In addition, it has launched a bi-weekly electronic publication called

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 “LHINsight” in which it proactively publicizes communication engagement activities.
Anyone who is interested may request to be on the electronic mailing list for this
publication.

138 The LHIN has also been involved in the provincial working group developing tools and
performance metrics for community engagement, which will include “ethical planning
guidelines” that would formally commit the LHIN to declare what community engagement
it is conducting and with whom. The LHIN expressed the view that the guidelines for
community engagement that are under development by the Ministry would not represent a
change for it, since they would merely formalize the LHIN’s current practices.

139 The LHIN has been involved as part of a national study group as well, working on
addressing what community engagement is, what works and what does not.

140 The LHIN indicated that it continues to engage with local media and politicians to discuss
community engagement. It has also held meetings with health service providers to talk
about the role of the LHIN and its expectations of health service providers with regard to
community engagement. The LHIN has recently encouraged greater sharing of
information with health service providers. Niagara Health System invited the LHIN to
participate in a series of community engagement meetings regarding the implementation of
the Hospital Improvement Plan and LHIN board members attended early community
sessions and other sessions as observers. The LHIN has also established an advisory
working group with Niagara Health System for monitoring implementation of the Hospital
Improvement Plan, including with regard to community engagement. A similar working
group has been established with Hamilton Health Sciences, and updates on community
engagement along with written updates on the implementation of the ABC plan are
provided to the LHIN board.

141 Finally, the LHIN has also added a section to its website called “Engaging you, our
community,” which provides general information on community engagement.

142 With respect to governance issues generally, the LHIN noted that it participated in a
review process, which included consideration of its practices, and that it was recognized as
a top performing board.

143 While the HNHB LHIN has taken some steps in the last year to provide more structure and
information surrounding its community engagement processes and to monitor the
community engagement undertaken by health service providers, there is still work to be
done in this regard. For instance, its website does not clearly distinguish the obligations
with respect to community engagement to be carried out by health service providers and
the LHIN itself, nor does it distinguish between instances where a voluntary plan is being
considered and those where the board has required a plan to be submitted.

144 In addition, I remain concerned that community engagement still appears to be an

amorphous concept that continues to include casual conversations in shopping lines or on

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 the golf course. Community engagement must be informed and not dependent on where
you shop or play. It is difficult to see how a casual conversation with the man or woman
on the street can be seen as satisfying any aspect of the LHIN’s community engagement
obligation.

145 It is possible that the current initiatives undertaken by the Ministry may provide greater
definition and certainty with respect to the community engagement obligations. However,
this clearly remains a work in progress. I will continue to closely monitor and assess the
progress made by the HNHB LHIN specifically, and by the Ministry generally with respect
to the broader LHIN community.

__________________________
André Marin
Ombudsman of Ontario

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Appendix

Final response letters from

Ministry of Health and Long-Term Care

and

Hamilton Niagara Haldimand Brant LHIN

!
WWWOMBUDSMANONCA &ACEBOOK /NTARIO /MBUDSMAN 4WITTER /NT?/MBUDSMAN